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Mercury policy and science in northeastern North America: the Mercury Action Plan of the New England Governors and Eastern Canadian Premiers.

In June 1998 the New England Governors and Eastern Canadian Premiers (NEG-ECP) adopted a comprehensive regional Mercury Action Plan (MAP) with aggressive emission reduction and pollution prevention goals for the New England States, the Atlantic Provinces and Quebec. New Jersey and New York have also been active participants. The NEG-ECP MAP was motivated by, and based on, extensive data demonstrating the widespread and serious nature of mercury impacts in the region and the existence of many preventable sources of mercury pollution. The plan established a long-term goal of virtually eliminating anthropogenic mercury releases in the region with interim goals of a 50% reduction by 2003 and 75% by 2010. Policy and regulatory initiatives implemented under the NEG-ECP MAP have exceeded federal efforts addressing mercury and have resulted in substantial regional progress in reducing mercury pollution. Recent data indicates that the region has reduced mercury emissions by approximately 55% since the NEGECP MAP was adopted. The NEG-ECP MAP provides an important demonstration of what can be technologically, economically and politically accomplished and has influenced mercury reduction programs at the global scale. Scientific information played important roles in developing and implementing this plan. Key research areas where regional policy makers would benefit from additional information include improved: environmental indicators for tracking progress; mercury release inventories, especially on mercury product breakage and mobile sources; deposition sources, including in-region and out-of-region contributors; elemental mercury exposure and impact data; determinants of mercury levels in fish; ecological impacts of mercury; and data on the effectiveness of outreach efforts.

Animals↗

Costs and prices for inpatient care in England: mirror twins or distant cousins?

The National Health Service (NHS) in England is introducing a national cost-per-case tariff system for the reimbursement of hospital services. Unlike most other countries with similar payment mechanisms, hospitals in England will have few alternative sources of income once the tariff system is fully implemented. This new financial regime generates powerful incentives for change, but exposes purchasers and providers to considerable financial risks. This paper examines the structure of the tariff. We describe how costs are determined, analyse the extent to which prices reflect costs, and review the results of an early evaluation of the system.

England↗

Trends for gonorrhea and pelvic inflammatory disease in England and Wales and for gonorrhea in a defined population.

Recent trends for gonorrhea and pelvic inflammatory disease in England and Wales are presented using routinely available data. The drawbacks of these data are examined, and a study is described which has attempted to rectify some of these inadequacies. The study attempted to identify patients with and without symptoms of gonorrhea, trichomoniasis, and candidiasis, living in a defined population. In addition, a calculation has been made of the number of cases of PID treated on an ambulatory basis in clinics for sexually transmitted disease in England and Wales.

Adolescent↗

Neurotoxic envenoming by an immigrant spider (Steatoda nobilis) in southern England.

A young woman was bitten on the shoulder by a female Steatoda nobilis spider, in Worthing on the south coast of England. She noticed intense radiating pain, local sweating (indicating parasympathetic stimulation) and feverishness. This immigrant species from the Canary Islands has established itself along the south coast of England in recent years. Like the related Mediterranean species S. paykulliana, S. nobilis may be of medical importance and deserves further study.

Adult↗

Effectiveness of BCG vaccination in England and Wales in 1983.

The effectiveness of BCG vaccination, at about age 13 years, in the prevention of tuberculosis at ages 15-24 years in England and Wales in 1983, has been determined by the same method as in two previous surveys in 1973 and 1978. In 1983, the tuberculosis notification rate among those vaccinated in the schools' scheme was 3.30 per 100,000, compared with an estimated rate of 13.20 per 100,000 among those who were tuberculin negative and not vaccinated in the scheme. The protective effectiveness of BCG vaccination at ages 15-24 years in England and Wales in 1983 is thus estimated as 75%; the estimated efficacy in the white ethnic group is closely similar, namely 76%. The estimated efficacy of BCG at ages 15-19 and 20-24 years in the three surveys, both in the white ethnic group and in the entire cohort, has been compared with that found in the Medical Research Council's controlled trial of tuberculosis vaccines which began in 1950. There is no evidence of any decrease in the protective efficacy of BCG vaccination between the four cohorts of young adults, which span a total period of 29 years. However, there were steep decreases between the cohorts in the annual notification rates for the white ethnic group; these decreases occurred in the BCG vaccinated and in the tuberculin negative unvaccinated groups, as well as among those found tuberculin positive (and not vaccinated) in the schools' scheme. It is concluded that the level of protective efficacy of BCG vaccination at ages 15-24 years is high, and has remained unchanged since the start of the BCG in schools' scheme. However, as the tuberculosis notification rate in young adults has decreased steeply throughout this period, and is continuing to decrease, the benefits to be expected from the BCG in schools' scheme will decrease equally rapidly.

Adolescent↗

PCBs and organochlorine pesticide residues in otters (Lutra lutra) and in otter spraints from SW England and their likely impact on populations.

PCB and organochlorine pesticide residues were determined in otter (Lutra lutra) spraints (faeces) from nine catchment regions in SW England over the period 1989-1991. Results of analyses of tissues from 22 otters are also presented. Dieldrin occurred in the majority of spraint samples and p,p-DDE and total PCBs in all. Lindane occurred mainly in samples collected in spring. Lindane was not found in otter tissues collected after 1991, but dieldrin, p,p-DDE and PCBs were found in all tissues. Dieldrin and p,p-DDE concentrations were strongly correlated in otter tissues, but there were no correlations with lindane or PCBs. Mean concentrations of contaminants varied widely between catchments. It was considered that PCBs were the compounds of most concern in influencing otter populations and that levels in spraints from one catchment were likely to be sufficiently high to exert a negative effect on populations. While levels of PCBs were elevated above background level in several other catchments and some individual otters had high levels of PCBs, it was considered that they were not sufficient to significantly hinder further population consolidation of otters in SW England.

Animals↗

International trends in cancer mortality in France, West Germany, Italy, Japan, England and Wales, and the USA.

Age-specific worldwide trends in cancer mortality were reviewed, with emphasis on cancer sites where increases have been reported in the USA. Cancer rates vary by factors as high as 30 between all countries, and 5-fold within and between industrialised countries. In Italy, Japan, Federal Republic of Germany, England and Wales, and the USA, patterns of cancer mortality have shifted uniformly over the past two decades. Stomach cancer continues to decline, while brain and other central-nervous-system cancer, breast cancer, multiple myeloma, kidney cancer, non-Hodgkin lymphoma, and melanoma have increased in persons aged 55 and older. Cancer of the lung is starting to decline for men under age 85 and women under age 60 in England and Wales and men under age 45 in the USA, but is still rising for men and women in other countries. All forms of cancer are increasing in persons over age 54 except lung and stomach (which together comprise between 20% and 43% of all cancer in males in these countries). Studies of the quality of ascertainment and enumeration indicate that these increases are not attributable solely to diagnostic artifacts or to increased access to health care, although both these factors may be involved. These recorded increases in cancer should be assessed in greater detail to provide better projections of health care needs and to identify causal factors that may be controlled. The changes in cancer other than lung are so great and rapid that their causes demand intensive investigation.

Adult↗

Group A meningococcal disease in England associated with the Haj.

An outbreak of group A meningococcal infection amongst the Muslim population in England followed the outbreak of meningococcal disease associated with the 1987 Haj to Mecca. There were 18 primary cases amongst pilgrims returning from Mecca and 15 subsequent cases among Muslims over the following 19 months. The meningococcal strains were shown to be of the same clone as strains from the Mecca outbreak by possession of an outer membrane protein PI.9. Strains of this group A clone (A III-I) had only rarely been encountered in England before this outbreak.

Adult↗

Age incidence of meningococcal infection England and Wales, 1984-1991.

The age incidence of meningococcal infections occurring between 1984 and 1991 in England and Wales was determined from data submitted with isolates to the Meningococcal Reference Laboratory for England and Wales. The incidence was maximum at 6 months of age and thereafter declined sharply to the age of 4 years. It was followed by a small secondary peak at 17-18 years. There was a relative excess of group B infections in the early months of life and, although group B and group C infections both peaked at 6 months of age, the latter did not decline until after the age of 9 months. Certain strains of meningococci were more likely to be associated with disease in older children and young adults.

Adolescent↗

The mortality of centenarians in England and Wales.

Vital statistics data previously published by the Registrar General of England and Wales have been separated into male and female deaths in 1960-69 aged 100, 1961-70 aged 101, 1962-71 aged 102 etc., to represent cohorts of 292 male and 1463 female centenarians born in 1859-1869. Mortality is fitted to age by the method of maximum likelihood. Estimated male mortality declines after age 103 and falls below that of females (who show no decline) at age 105. The cause of this non-Gompertzian tapering off in mortality is found to be selection due to variability in the males, which is more than sufficient to offset the biological effects of aging that nevertheless occur in each individual. Selection causes a reduction of 0.01 per year of age in mean male centenarian mortality rates in England and Wales.

Aged↗

The expectation of life without disability in England and Wales.

This paper calculates the Expectation of Life Without Disability (ELWD) for England and Wales, following the method of Robine et al. (Population 6, 1025-1042, 1986), using a question about limiting long-standing illness from the General Household Survey. Trends over the last decade are estimated. At present ELWD from birth is about 59 years for men, 62 for women. The trend is upward, but by no more and possibly less than the rate of increase in expectation of life. Men live a greater proportion of their lives without disability than do women. The improvement in ELWD is most marked in the highest age-groups, but the evidence is that the health of the elderly in relation to that of the population as a whole has been poorer in England and Wales than in two other countries for which similar evidence is available.

Activities of Daily Living↗

Socioeconomic factors and the incidence of hospitalized burn injuries in New England counties, USA.

This study demonstrates that readily available socioeconomic data routinely collected by the US Census can be used to estimate the incidence of burn injuries within the 66 counties of the populous six-state New England region of the USA. The burn data were collected during the National Burn Demonstration Project and included New England residents admitted for hospital care of burns sustained between 1 July 1978 and 30 June 1979. Linear regression analysis revealed strong associations between calculated burn rates and a number of socioeconomic variables. Associations with five such variables are described, including per capita income, percentage of persons below poverty level, percentage of residences built prior to 1940, percentage of adults with 16 years or more of education, and percentage of persons moving since 1975 with previous residence in the same county. Estimates of burn incidence for counties, together with a previously reported study at the level of census tracts for a major Standard Metropolitan Statistical Area, can be used to reduce the time and cost of burn injury case reporting by health care providers or case-finding efforts for large population groups, and can be used to predict the effectiveness of social and economic programmes and policies that improve the overall well-being of county populations.

Burns↗

Rural in-migration in England and Wales, 1980-1981.

"A partially constrained Poisson regression model approach was used to examine 31,356 district-level flows into and between rural areas in England and Wales between 1980 and 1981.... The results suggest that military redeployment was of considerable importance in explaining the patterns of rural in-migration in England and Wales between 1980 and 1981. Little evidence of a major redistribution of population from the largest urban centres to the rural periphery was identified."

Demography↗

Geographical and social class effects on asthma mortality in England and Wales.

To determine whether asthma mortality is influenced by geographical or social factors, a retrospective analysis of deaths from asthma in England and Wales between 1979-1987 was performed. Death rates in the 15 Regional Health Authority areas of England and Wales were stratified by sex, age group (0-4, 5-34, 35-64, and > 64 years), and occupational social class. Detailed analysis was restricted to subjects aged 5-64 years because adequate social class data was only available over this age range. Death rates were higher in manual occupational groups (social class IIIb-V) than in non-manual occupations (social class I-IIIa), but on further analysis this effect was confined to males aged 35-64 years. In younger subjects (5-34 years), mortality was higher in the south of the country, and this difference was significant in males (P < 0.05). In older subjects (35-64 years), mortality in both sexes was significantly higher in the north of the country. This study demonstrates that mortality is not evenly distributed between social classes or regions of the country.

Adolescent↗

HIV-related tuberculosis in England and Wales.

Numbers of tuberculosis notifications in England and Wales increased by 8% from 1987 to 1989. An analysis of notifications by age and sex has been undertaken to determine whether this increase has been due to an increase in young male adults, as has occurred in the USA, implying that HIV is largely responsible for the increase in notifications. Though notifications increased by 9.5% in younger males between 1987 and 1989 they also increased by over 10% amongst most age groups of females, and elderly males. These findings would suggest that there are a number of factors causing a rise in tuberculosis notifications, and that HIV is not yet directly implicated in England and Wales.

Adolescent↗

The effects of area deprivation on the incidence of child and adult pedestrian casualties in England.

This paper analyses child pedestrian casualties in England, focusing on the influence of socio-economic deprivation. It develops an area-based model of pedestrian casualties and presents estimates based on data for the English wards. The results detect an association between increased deprivation and higher numbers of pedestrian casualties across England. The deprivation effect is strong both for all child casualties and for children killed or seriously injured. Estimates for adult casualties also reveal a positive and significant association with increasing deprivation, but the magnitude of the effect is smaller than for children. The paper concludes by outlining some of the implications of the research.

Accidents, Traffic↗

Cardiovascular risk profiles in UK-born Caribbeans and Irish living in England and Wales.

Cardiovascular disease is the leading cause of morbidity and mortality among Caribbean and Irish origin people living in England and Wales. Yet mortality from coronary heart disease (CHD) of migrant Caribbeans is lower than the national average, while stroke mortality is higher. The Irish experience higher than average mortality from both diseases. Little is known about the health of the children of these migrants. The Health Survey for England (HSE) 1999 was used to investigate for the first time cardiovascular risk factors in UK-born Caribbeans aged 35-44 and Irish aged 35-44 and 45-54 years. Caribbean men were more likely to smoke but had higher mean HDL-cholesterol than men in the general population. Caribbean women had greater body mass indices and lower mean triglyceride levels. Irish men in both age groups smoked more than men in the general population, but in the younger group had lower diastolic blood pressure (BP). At age 35-44 only, Irish women were shorter than women in the general population. These findings were independent of differences in socio-economic position. Previously, Caribbean-born migrants to Britain had generally favourable lipid profiles in line with lower CHD rates, despite obesity and diabetes. The nationally representative but small-scale data presented here suggest that UK-born Caribbeans appear to be losing this more favourable lipid pattern and among men smoking rates are now higher compared with general population men, suggesting that an increase in CHD rates can be expected. Further research should examine how improved education and specific intervention programs could be used to reduce smoking among UK-born Irish and Caribbean men, and obesity among UK-born Caribbean women. The next HSE also needs to include adequate numbers of younger people of different ethnic origins to allow time trends in these anthropometric, behavioural and metabolic risk factors to be examined reliably and fully.

Adult↗

Breast cancer multi-disciplinary teams in England: much achieved but still more to be done.

OBJECTIVE: To look at the national coverage, composition and discussion of breast cancer multi-disciplinary teams (MDTs) in England. DESIGN AND DATA SOURCE: All breast units in England both symptomatic and screening were sent a questionnaire. MAIN OUTCOME MEASURES: Attendance of core members at MDT meetings; Percentage of patients discussed with a treatment plan; Private patients discussed; Reconstructive surgery. RESULTS: The majority of core members of the breast MDT attend weekly meetings to discuss the multidisciplinary management of patients with breast cancer, although attendance by medical oncologists and reconstructive breast surgeons is limited. Three MDTs never had a radiologist present and 3 never had a pathologist present at the MDT meeting. Most breast MDTs have a meeting coordinator to collect case-notes, radiographs and pathology reports to facilitate the meeting. Seventy-nine out of 134 teams discuss every cancer patient and 118 also discuss private patients. Twenty-seven teams record the outcome of the MDT meeting electronically, 32 teams book surgery, 16 radiotherapy and 15 book chemotherapy direct from the MDT meeting.

Breast Neoplasms↗